Healthcare Provider Details

I. General information

NPI: 1659687432
Provider Name (Legal Business Name): ELIZABETH A PICKERING PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LIZ A PICKERING PA-C

II. Dates (important events)

Enumeration Date: 08/31/2010
Last Update Date: 11/19/2021
Certification Date: 11/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 N COUNTY ROAD 2050 E
CARTHAGE IL
62321-3551
US

IV. Provider business mailing address

PO BOX 160
CARTHAGE IL
62321-0160
US

V. Phone/Fax

Practice location:
  • Phone: 217-357-2173
  • Fax: 217-357-3610
Mailing address:
  • Phone: 217-357-8500
  • Fax: 217-357-8697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60180643
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085007854
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: